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OFF WITH THE OLD 30 MARCH 2015 | Med Esthetics Medium to Deep Resurfacing For many years, medium-to-deep chemical peels and dermabrasion were the treat- ments of choice for patients with deep wrinkles and those with acne scarring. To- day, these modalities have largely—though not entirely—been replaced by fractional laser skin resurfacing. "Factoring in my train- ing, I have historically done Jessner peels and really deep peels. The problem with medium and deep peels is that the control is all in the person's hand and how much is applied," says Jennifer Reichel, MD, owner and director of the Pacifi c Dermatology & Cosmetic Center in Seattle. "As opposed to lasers where, if you pick a setting, you know that you're going to get an even treatment across the entire surface. So when you get into that deeper resurfacing, I tend to move toward lasers because they're safer." For patients with severe photodamage, including deep wrinkles, and signifi cant actinic keratoses (AKs) and dyschromia, Bruce Katz, MD, owner and director of JUVA Skin & Laser Center in New York, also opts for frac- tional CO 2 resurfacing. If the patient can toler- ate signifi cant downtime of 7 to 10 days, he performs a single, higher-density treatment. But more commonly, he treats patients with multiple sessions delivered at lower energy and density settings. "Here in New York, most of our patients are not interested in signifi cant downtime," he says. "I might do four or fi ve sessions of fractional CO 2 at low density and low energy, performed at two- to three-week intervals. People get signifi cant benefi ts without the downtime." Suzan Obagi, MD, director of the Cos- metic Surgery and Skin Health Center at the University of Pittsburgh Medical Center, performs both fractional laser skin resur- facing and medium depth chemical peels. Speaking at the 31 st Annual Meeting of the American Academy of Cosmetic Surgery, she noted that the patient's skin color, skin thickness, depth of the skin problem, toler- ance for downtime and number of treat- ment sessions all factor into her treatment recommendations. If she is trying to reach the deep dermis, "I may lose control of the peel, so I may choose a laser for this patient," she says. In the case of patients with lighter skin types and signifi cant melasma, she tends to recommend chemical peels. "I do not want to generate heat for this patient, so I would likely choose a peel," she says. She notes that patients with thicker skin are harder to peel and may, therefore, be better candidates for laser resurfacing. In some cases, Dr. Obagi combines fractional ablative resur- facing with chemical peels. "You can't laser everywhere, for example on the neck and the eyebrows," she notes. "I may resurface with the laser and then use a chemical peel to 'feather' around the eyes, brows, neck and hairline to avoid lines of demarcation." Patients with darker skin types can experi- ence post-infl ammatory hyperpigmentation (PIH) following both laser skin resurfacing and deeper chemical peels. "A lot of people have darker skin tones, and you have to be very careful with the heat from the laser, so that's not always a proper treatment for those patients," says Andrea Fairman, a licensed esthetician with Colorado Plastic Surgery Center in Littleton, Colorado. "The same can be true of peels, but with a lot of the newer peel formulations you can be very safe with the darker skin tones and still offer a fairly aggressive peel." You can reduce the risk of PIH by prep- ping the skin. "There are some peels out there that are safe for skin types IV and V. However, depending on the peel, it's wise to pretreat and strengthen the patient's skin, and get them on pigment inhibitors to suppress the melanocytes," says Fairman. "Ultimately, they're going to get better re- sults if they're prepping their skin, because the skin is in better condition, and it does reduce the risk of side effects." For patients with darker skin tones and acne scarring, which requires deep resurfac- ing, Dr. Obagi pretreats the skin with reti- noids and bleaching agents. She then offers a combination treatment of fractional CO 2 resurfacing and chemical peels, using the peel after the laser procedure to help blend the treated area. Because patients with acne scarring require multiple treatments, Dr. Reichel recommends nonablative fractional laser resurfacing to her patients. "I had fi ve patients who came in with acne scarring, and we tried a series of four fractional CO 2 treatments. None of them got through more than two, because it's so diffi cult to heal from," she says. "Whereas with the nonablative Fraxel Re:store, you're healed in three or four days. People will undergo six to eight of those treatments, and it gives them a better result than one CO 2 ." A relatively new option for acne scarring is the 755nm Picosure (Cynosure) picosec- ond laser. "For acne scarring, there's a new type of laser we're using, which is the Picosure, and that's been very nice and has minimal downtime," says Dr. Katz. Superfi cial Resurfacing Though Dr. Reichel and Dr. Katz prefer lasers for deeper resurfacing needs, they both agree that chemical peels continue to offer valuable benefi ts for superfi cial resurfac- ing in patients with fi ne lines and minor © GETTY IMAGES Patients with thicker skin are harder to peel and may, therefore, be better candidates for laser resurfacing.